DOMICILIARY MEDICATION MANAGEMENT – HOME MEDICINES REVIEW Provider/Patient details may be completed by the practice staff

The DMMR referral should include relevant information (e.g. laboratory results) to enable the pharmacist to make a thorough assessment. Please review the patient’s medical record and any previous health assessments, care plans, and case conference summaries for relevant information. Completing the referral form* in detail will reduce the possibility of the pharmacist needing to contact you to clarify background information. Relevant information from the patient’s medical record may be attached to the referral form e.g. as a printout from your patient record system. *If you are not using a specific DMMR referral form you still need to provide patient details and relevant clinical information to the pharmacist. Additional forms are available on the Department of Health and Ageing’s website. See www.health.gov.au/mbsprimarycareitems COMMUNITY PHARMACY / ACCREDITED PHARMACIST DETAILS

(nominated by the patient)

Name: ____________________________

PATIENT DETAILS (or affix label with patient details here)

Name: _____________________________

Address: ___________________________

___________________________________

___________________________________

D.O.B.: ____________________________

Medicare No: _______________________

DVA No: __________________________

Patient/Carer contact: _________________

ISSUES THAT MAY INFLUENCE MEDICATION USE OR EFFECTIVENESS

□ Vision □ Hearing

□ Language and/or □ Swallowing Literacy problems

□ Cognition □ Dexterity (Memory and (e.g. manual Comprehension) coordination)

□ Other

OTHER PATIENT INFORMATION

Height: ________________ cm

Weight: ________________ kg

Blood Pressure: ____________

VACCINATION STATUS (Tick if up to date) □ Tetanus □ Rubella □ Hepatitis A □ Hepatitis B □ Influenza

GENERAL PRACTITIONER DETAILS

Name: ___________________________ Address: __________________________

__________________________________

__________________________________

Provider No.: ______________________

Prescriber No.: _____________________

Phone: ___________________________

Fax: ______________________________

Email: ____________________________

Preferred means of receiving report:

__________________________________

DOES PATIENT SMOKE?

□ Yes □ No □ Ex-smoker

DOES PATIENT DRINK?

□ Doesn’t drink □ Approx _____ drinks per week

MEDICATION DOSE ADMINISTRATION:

□ Self □ Partner/Carer

AIDS OR OTHER EQUIPMENT USED:

□ Peakflow meter □ Spacer □ Nebuliser □ Blood Glucose meter □ Multi/unit dose □ Other ______________ DAA e.g. Dosette

INDICATION FOR DMMR ____________________________________________

____________________________________________

____________________________________________

ALLERGIES OR ADVERSE REACTIONS TO MEDICATION DRUG REASON FOR PRESCRIPTION REACTION

CURRENT CONDITIONS AND MEDICATIONS CONDITIONS /DIAGNOSIS e.g. DIABETES

MEDICATION OR OTHER TREATMENT e.g. Daonil or Diet

STRENGTH, DOSAGE AND FREQUENCY e.g. 5mg before breakfast

THERAPEUTIC GOALS e.g. Sugar control

ISSUES e.g. Visual problems

RELEVANT LABORATORY RESULTS AND BLOOD DRUG LEVELS TEST TYPE DATE ISSUES

I HAVE EXPLAINED TO THE PATIENT: the process involved in having a DMMR and;

THE PATIENT UNDERSTANDS THAT: the location of the DMMR is at their choice,

but preferably in their own home; and the pharmacist who will conduct the DMMR

will communicate with me information arising from the DMMR; and

THE PATIENT HAS CONSENTED: to me releasing to the pharmacist information

about their medical history and medications; and

THE PATIENT HAS/HAS NOT CONSENTED: to me releasing their Medicare No. or DVA

No. to the pharmacist for the pharmacist’s payment purposes. *

Date: ___________________________ General Practitioner’s Signature: _____________________________ * If the patient does not agree to release their Medicare No., the DMMR service can still be provided.

DOMICILIARY MEDICATION MANAGEMENT – HOME MEDICINES REVIEW

ACKNOWLEDGEMENT OF RECEIPT OF REFERRAL

From (community pharmacy/accredited pharmacist): _____________________________________

I have arranged to conduct a DMMR for: ____________________________ (Patient’s name)

on __________________ .

Pharmacist conducting interview: ____________________________________________________

Signed: _________________________________________________________________________